Out, Damned Spot!
By: B. Aviva Preminger, MD, MPH, FACS
“Out, damned spot! Out, I say!” cried Lady Macbeth in Shakespeare’s famous tragedy, desperately trying to wash away an imaginary bloodstain from her hands. While her spots were a manifestation of guilt, the spots that concern many of my patients are far more real and, fortunately, much easier to remove.
Summer may be a distant memory by now, but its effects often linger long after the beach chairs have been folded, the bathing suits put away, and the last of the sunscreen bottles discarded. Perhaps you spent a few too many afternoons at the beach, enjoyed long walks in the sunshine, or simply forgot to reapply sunscreen as frequently as you should have (which should actually be daily, even in the winter months for the record!)? Whatever the reason, you may notice some unwelcome souvenirs of summer when you look in the mirror such as brown spots, freckles, uneven pigmentation, and an overall complexion that looks a little less clear than it did before.
Before going any further, let me make an important distinction. I am not referring to new or changed pigmented moles. Any new, unusual, or evolving pigmented lesion, particularly one that changes in size, shape, or color, has irregular borders, or bleeds, should be evaluated by a dermatologist to rule out skin cancer. These are not spots to be casually zapped away with a laser or light treatment. Rather, I am talking about the more generalized pigmentation that develops from cumulative sun exposure. These are the little sometimes confluent brown spots scattered across our cheeks, foreheads, noses, and décolletage that can make our skin appear older than we feel.
The good news? Modern technology offers us some remarkable ways to address them. Fall and winter happen to be among my favorite times of year to do just that.
Our skin contains cells called melanocytes, which produce melanin, the pigment responsible for giving our skin its color. Melanin serves a protective function, helping shield the skin from ultraviolet radiation. When we spend time in the sun, these cells respond by producing more pigment. This is what gives us a tan. Unfortunately, the process isn’t always uniform. Over time, repeated sun exposure can cause pigment to accumulate unevenly, resulting in freckles, sunspots (also called solar lentigines), and an overall mottled appearance. While a summer tan may initially seem appealing, it is actually evidence of the skin responding to ultraviolet injury. With enough accumulated exposure, that once-even complexion may begin to resemble a map of summers past, and signal others how many years of summers that has actually been!
One of my favorite treatments for sun-related pigmentation is IPL, or intense pulsed light. Patients often refer to IPL as a laser, although technically it is not one. To understand the difference, it helps to understand a little about how lasers work. The word LASER is actually an acronym for Light Amplification by Stimulated Emission of Radiation. That sounds intimidating, but the concept is relatively straightforward. Think about sunlight passing through a prism and separating into the colors of the rainbow (remember that “ROY G BIV” spectrum from your high school biology textbooks?). Different colors of light represent different wavelengths, and different wavelengths interact with the skin in different ways. A laser produces a concentrated beam of light at a specific wavelength. That wavelength can be selected to target a particular substance in the skin. For example, certain wavelengths are preferentially absorbed by melanin, the pigment responsible for brown spots. Others are absorbed by hemoglobin, the pigment in blood that contributes to redness and visible blood vessels. Still others target water within the skin and can be used for resurfacing and stimulating skin remodeling. When the targeted substance absorbs the light energy, that energy is converted into heat. By carefully controlling the wavelength, intensity, and duration of the pulse, we can selectively treat unwanted pigment or blood vessels while minimizing injury to the surrounding tissue. This principle is known as selective photothermolysis. It’s a complicated term for a wonderfully elegant idea that is using light to heat a specific target without unnecessarily damaging everything around it. IPL works on a similar principle, but rather than emitting one specific wavelength, it delivers a broad spectrum of light that can be filtered to address different concerns.
That versatility is what makes IPL so useful. In a single treatment session, we can often address brown pigmentation, redness, small visible blood vessels, and the overall uneven skin tone that accompanies years of sun exposure.
During an IPL treatment, pulses of light are delivered through a handheld device placed against the skin. Patients typically describe the sensation as a quick snap of a rubber band. It is generally well tolerated, and treatment of the face usually takes less than half an hour.
In the days following treatment, the brown spots may actually become darker before they become lighter. This is not necessarily a sign that something has gone wrong. In fact, it is often an expected part of the process. The pigment absorbs the light energy, and the treated spots can temporarily take on a darker, coffee-ground appearance before gradually flaking away or fading over the following week or two. The result is often a clearer, brighter, more even complexion.
Unlike more aggressive resurfacing treatments, IPL generally requires little downtime. Patients may experience some temporary redness or mild swelling, but most can return to their normal routines relatively quickly. Depending on the degree of pigmentation, several treatments may be recommended for optimal results.
Of course, not all pigmentation is created equal. Melasma, for example, is a more complicated condition influenced by hormones, sun exposure, and other factors. It may actually worsen with certain light-based treatments. Patients with darker skin tones or recently tanned skin also require particular caution because of the risk of burns or unwanted changes in pigmentation. This is why proper patient selection and an accurate diagnosis are so important.
One of the questions I frequently hear is, “When is the best time to have laser treatments?”
My answer is: right now.
This is the perfect window after the holidays, before any planned Caribbean vacations. As the days grow shorter and the temperature drops, most of us are spending less time outdoors. Our summer tans have faded, and the intensity of our sun exposure has generally decreased. This makes fall and winter particularly appealing seasons for IPL and many other laser treatments. Treating recently tanned skin increases the risk of complications because the extra melanin in the skin can absorb light energy that is intended for the unwanted spots. Similarly, exposing freshly treated skin to significant sunlight can increase the risk of post-inflammatory hyperpigmentation. By scheduling treatments during the cooler months, patients often find it easier to avoid excessive sun exposure both before and after their procedures.
That doesn’t mean sunscreen can be put away until Memorial Day. Ultraviolet radiation is present year-round, even on cold or cloudy days. I recommend daily broad-spectrum sunscreen with an SPF of at least 30, regardless of the season. After all, there is little point in treating years of accumulated sun damage only to invite it back the following summer.
As a plastic surgeon, I spend much of my professional life thinking about the relationship between appearance and aging. We often focus on wrinkles, sagging skin, and changes in facial volume. But skin quality and the evenness of our complexion play an enormous role in how youthful and healthy our faces appear. Sometimes, improving the color and clarity of the skin can make a surprisingly significant difference, even without changing a single wrinkle.
We cannot erase every consequence of summers past, nor should we expect our skin to look exactly as it did when we were twenty. But with thoughtful treatment, appropriate technology, and a renewed commitment to sun protection, we can certainly improve some of the visible evidence.
Lady Macbeth may have discovered that no amount of scrubbing could remove her imaginary spot. Fortunately, when it comes to the sunspots on our faces, modern medicine gives us considerably more effective options.
Unlike Lady Macbeth, we can look forward to a much happier ending!
At Preminger Plastic Surgery, we are committed to educating our patients and providing personalized care tailored to their unique needs. For those considering plastic surgery, we offer guidance every step of the way to help you achieve your aesthetic and wellness goals. Dr. Preminger is a board-certified plastic surgeon with degrees from Harvard, Cornell, and Columbia.
For more information or to schedule a consultation, please visit premingermd.com or call 212-706-1900. Follow us on Instagram @premingerplasticsurgery.
